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Amsterdam April 2011
Do unexplained symptoms predict anxiety or depression in
primary care.
Kees van BovenPeter Lucassen,Tim OldeHartmanHiske van RavesteijnSibo OskamHans BorEvelyn van Weel-BaumgartenChris van Weel.
Quizz
Research questions
Transition project
Physical symptomsMental health problems
Conclusion and Discussion
Presentation Contents
Symptoms are sometimes the manifestation of a disease; frequently symptoms are not explained by disease. In the latter case, the general practitioner makes a ‘symptom diagnosis’.What percentage of all diagnoses of a general practitioner per year is a ‘symptom diagnosis’?
O 0–10%
O 10-20%
O 20-30%
O 30-50%
• Part of the patients in primary care very frequently present unexplained symptoms i.e. symptoms not explained by disease.
• What percentage of all patients in primary care do very frequently present unexplained symptoms?
•O 0-2%
•O 2-4%
•O 4-6%
•O 6-8%
In how many patients with unexplained symptoms is depression or anxiety the causes of the symptoms?
O 0-5%
O 5-10%
O 10-15%
O 15-20%
Research questions
• Are mental health problems associated with unexplained symptoms presented to the GP?
• Do unexplained symptoms, presented to the GP, predict a mental health problem?
Transition Project
16 000 patientsICPC classification
DataPatients followed for 1-11 years (1997 – 2008)419056 encounters with patients >=15 year
ICPC codes Reason for encounter Diagnosis Intervention
Structured in an Episode of care
Somatoform symptoms Somatic symptoms
Number of episodes between 1997 and 2008
Year prevalence (%)
Number of episodes between 1997 and 2008
Year prevalence
tiredness 5179 3,8 lymph gland enlargement
571 0,4
fainting 939 0,7 localized abdominal pain
2888 2,1
abdominal pain
582 0,4 diarrhea 865 0.6
nausea 681 0,5 red eye 350 0,3
constipation 2741 2,0 swollen ankles 1524 1,1
palpitations 1288 0,9 shoulder symptoms
2397 1,7
low back complaints
6625 4,8 hand/finger symptoms
1480 1,1
Somatoform symptoms episodes Somatic symptoms episodes
Number of episodes between 1997 and 2008
Year prevalence (%)
Number of episodes between 1997 and 2008
Year prevalence
chest symptoms
3367 2,5 hip symptoms 1164 0,9
muscle pain 1358 1,0 tingling fingers/toes/feet
335 0,2
headache 2353 1,7 cough 3998 2,9
dizziness 2035 1,5 throat symptoms 2294 1,7
disturbances of sleep
3661 2,7 pruritus 1378 1,0
shortness of breath
1008 0,7 urinary frequency
856 0,6
total 31817 23,1 total 20100 14,6
Odds Ratios
Somatoform symptoms
Anxiety disorderOR
Anxiety disorder95% CI
Depressive disorderOR
Depressive disorder95% CI
tiredness 1,85 1,53-2,23 2,85 2,61-3,12fainting 2,44 1,69-3,52 2,16 1,75-2,68abdominal pain 4,49 3,20-6,30 1,99 1,52-2,61
nausea 3,08 2,23-4,26 4,24 3,60-5,00constipation 1,97 1,63-2,38 3,79 3,49-4,12palpitations 4,7 3,74-5,89 2,49 2,11-2,94low back complaint 1,72 1,47-2,02 1,7 1,56-1,86
chest symptoms 2,79 2,29-3,39 1,83 1,61-2,08
muscle pain 5,09 4,11-6,31 2,88 2,47-3,35headache 2,95 2,41-3,61 2,49 2,21-2,81dizziness 2,62 2,07-3,31 2,25 1,96-2,59disturbances of sleep 2,55 2,23-2,92 4,08 3,82-4,36
shortness of breath 2,13 1,48-3,07 3,15 2,64-3,75
Cross-sectional analysis of data with a time frame of one year. Association of somatoform and somatic symptoms with anxiety and depressive disorder (ORs, 95%Ci)
Odds Ratios
Somatic symptoms Anxiety disorderOR
Anxiety disorder95% CI
Depressive disorderOR
Depressive disorder95% CI
lymph gland enlargement
2,59 1,62-4,15 0,69 0,43–1,11
localized abdominal pain
1,68 1,30-2,17 2,03 1,79-2,32
diarrhea 2,66 1,98-3,59 3,02 2,58-3,55red eye 1,25 0,59-2,64 1,47 1,01-2,14swollen ankles 1,65 1,23-2,22 3,05 2,68-3,47shoulder symptoms 1,59 1,20-2,11 1,6 1,37-1,86hand/finger symptoms 1,94 1,39-2,71 1,84 1,53-2,22
hip symptoms 0,92 0,55-1,54 2,06 1,70-2,51tingling fingers/toes/feet
2,65 1,49-4,72 2,01 1,40-2,88
cough 1,47 1,21-1,80 1,84 1,66-2,04throat symptoms 1,56 1,17-2,09 1,56 1,34-1,83pruritus 2,35 1,80-3,09 2,43 2,09-2,82urinary frequency 2,42 1,66-3,51 2,47 2,01-3,03
Cross-sectional analysis of data with a time frame of one year. Association of somatic symptoms with anxiety and depressive disorder (ORs, 95%Ci)
number of symptoms
number of patients no depression or anxiety (%)
depression or anxiety (%)
Somatoform symptoms episodes
0 8447 98,83 1,17
1 1357 96,61 3,39
2 or more 335 94,03 5,92
Somatic symptom episodes
0 8782 98,54 1,46
1 1156 97,66 2,34
2 or more 201 95,02 4,98
Cross-sectional analysis in a time frame of one year (2007). Percentages of patients with/without anxiety or depression in patients presenting with different numbers of symptom episodes.
Anxiety disorderSomatoform symptom episodes
pretest posttest Positive predictive value
Negative predictive value
tiredness 0,004 0,003 0,003 0,996
fainting 0,004 0,004 0,004 0,997
abdominal pain 0,004 0,004 0,004 0,997
nausea 0,004 0,007 0,007 0,997
constipation 0,004 0,003 0,003 0,996
palpitations 0,004 0,013 0,012 0,997
low back complaint 0,004 0,001 0,001 0,996
chest symptoms 0,004 0,004 0,004 0,997
muscle pain 0,004 0,002 0,002 0,996
headache 0,004 0,004 0,004 0,997
dizziness 0,004 0,004 0,004 0,997
disturbances of sleep 0,004 0,008 0,008 0,997
Shortness of breath 0,004 0,006 0,006 0,997
Anxiety disorder
Somatic symtom episodes
pretest posttest Positive predictive value
Negative predictive value
lymph gland enlargement
0,004 0,002 0,002 0,996
localized abdominal pain 0,004 0,002 0,002 0,996
diarrhea 0,004 0,004 0,004 0,997
red eye 0,004 0,000 0,000 0,996
swollen ankles 0,004 0,001 0,001 0,996
shoulder symptoms 0,004 0,002 0,002 0,996
hand/finger symptoms 0,004 0,001 0,001 0,996
Hip symptoms
hand/finger symptoms 0,004 0,002 0,002 0,996
tingling fingers/toes/feet 0,004 0,003 0,003 0,997
cough 0,004 0,002 0,002 0,996
throat symptoms 0,004 0,004 0,004 0,997
pruritus 0,004 0,002 0,002 0,996
urinary frequency 0,004 0,003 0,003 0,997
Depressive disorderSomatoform symptoms pretest posttest Positive predictive
valueNegative predictive value
tiredness 0,014 0,014 0,014 0,986
fainting 0,014 0,014 0,014 0,986
abdominal pain 0,014 0,010 0,010 0,986
nausea 0,014 0,021 0,021 0,986
constipation 0,014 0,014 0,014 0,986
palpitations 0,014 0,012 0,012 0,986
low back complaint 0,014 0,007 0,007 0,986
chest symptoms 0,014 0,005 0,005 0,986
muscle pain 0,014 0,008 0,008 0,986
headache 0,014 0,011 0,011 0,986
dizziness 0,014 0,009 0,009 0,986
disturbances of sleep 0,014 0,026 0,025 0,986
shortness of breath 0,014 0,015 0,014 0,986
Somatic symptoms pretest posttest Positive predictive value
Negative predictive value
lymph gland enlargement
0,014 0,005 0,005 0,986
localized abdominal pain 0,014 0,008 0,008 0,986
diarrhea 0,014 0,013 0,013 0,986
red eye 0,014 0,005 0,005 0,986
swollen ankles 0,014 0,013 0,012 0,986
shoulder symptoms 0,014 0,009 0,009 0,986
hand/finger symptoms 0,014 0,006 0,006 0,986
Hip symptoms
hand/finger symptoms 0,014 0,005 0,005 0,986
tingling fingers/toes/feet 0,014 0,000 0,000 0,986
cough 0,014 0,008 0,008 0,986
throat symptoms 0,014 0,007 0,007 0,986
pruritus 0,014 0,007 0,007 0,986
urinary frequency 0,014 0,013 0,013 0,986
Odds Ratios Somatic symptoms Anxiety disorder
ORAnxiety disorder95% CI
Depressive disorderOR
Depressive disorder95% CI
lymph gland enlargement
2,59 1,62-4,15 0,69 0,43–1,11
localized abdominal pain
1,68 1,30-2,17 2,03 1,79-2,32
diarrhea 2,66 1,98-3,59 3,02 2,58-3,55
red eye 1,25 0,59-2,64 1,47 1,01-2,14
swollen ankles 1,65 1,23-2,22 3,05 2,68-3,47
shoulder symptoms 1,59 1,20-2,11 1,6 1,37-1,86
hand/finger symptoms
1,94 1,39-2,71 1,84 1,53-2,22
hip symptoms 0,92 0,55-1,54 2,06 1,70-2,51
tingling fingers/toes/feet
2,65 1,49-4,72 2,01 1,40-2,88
cough 1,47 1,21-1,80 1,84 1,66-2,04
throat symptoms 1,56 1,17-2,09 1,56 1,34-1,83
pruritus 2,35 1,80-3,09 2,43 2,09-2,82
urinary frequency 2,42 1,66-3,51 2,47 2,01-3,03
Cross-sectional analysis of data with a time frame of one year. Association of somatic symptoms with anxiety and depressive disorder (ORs, 95% CIs)
Odds Ratios Somatic symptoms Anxiety disorder
ORAnxiety disorder95% CI
Depressive disorderOR
Depressive disorder95% CI
lymph gland enlargement
2,59 1,62-4,15 0,69 0,43–1,11
localized abdominal pain
1,68 1,30-2,17 2,03 1,79-2,32
diarrhea 2,66 1,98-3,59 3,02 2,58-3,55
red eye 1,25 0,59-2,64 1,47 1,01-2,14
swollen ankles 1,65 1,23-2,22 3,05 2,68-3,47
shoulder symptoms 1,59 1,20-2,11 1,6 1,37-1,86
hand/finger symptoms
1,94 1,39-2,71 1,84 1,53-2,22
hip symptoms 0,92 0,55-1,54 2,06 1,70-2,51
tingling fingers/toes/feet
2,65 1,49-4,72 2,01 1,40-2,88
cough 1,47 1,21-1,80 1,84 1,66-2,04
throat symptoms 1,56 1,17-2,09 1,56 1,34-1,83
pruritus 2,35 1,80-3,09 2,43 2,09-2,82
urinary frequency 2,42 1,66-3,51 2,47 2,01-3,03
Cross-sectional analysis of data with a time frame of one year. Association of somatic symptoms with anxiety and depressive disorder (ORs, 95% CIs)